Provider Demographics
NPI:1588279657
Name:INNOVAGE PENNSYLVANIA LIFE, LLC
Entity type:Organization
Organization Name:INNOVAGE PENNSYLVANIA LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:DEBORAH
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-242-1352
Mailing Address - Street 1:8950 E LOWRY BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7030
Mailing Address - Country:US
Mailing Address - Phone:844-292-1028
Mailing Address - Fax:303-869-4664
Practice Address - Street 1:4401 MEGARGEE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-2160
Practice Address - Country:US
Practice Address - Phone:844-292-1028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOTAL COMMUNITY OPTIONS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization